Editor’s note: This is part one of a two-part series exploring Medicare special needs plans (SNP).
Special needs plans—including chronic condition special needs plans (C-SNP)—continue their rise in the Medicare market in 2008, with a growth rate of 60% and the advent of the country’s first such plan developed specifically for beneficiaries with Alzheimer’s disease.
In late December 2007, CMS announced that it is working with the National Committee for Quality Assurance (NCQA) on quality measures for Medicare SNPs. These structure and process measures were scheduled to be released by NCQA March 15. What makes SNPs a successful business model for DM in the Medicare population, and what have the successful SNPs learned? Offering an SNP is seen as a good business investment, but a risky one.
“These are the beneficiaries that are costing Medicare the most because they have multiple chronic conditions,” says Fred Dodson, executive vice president of Care Improvement Plus, the C-SNP run by XLHealth, headquartered in Baltimore. Beneficiaries who enroll in the C-SNP have one or more of four chronic conditions: diabetes, chronic heart failure, chronic obstructive pulmonary disease, and/or end state renal disease.
“Two of our key focus areas are managing members appropriately in order to maximize the quality of their lives and reviewing documentation to ensure appropriate reimbursement,” Dodson says.
His company places a strong emphasis on documentation and coding, in addition to offering what Dodson calls “an attractive product that brings disease management into a Medicare Advantage plan.”
Dodson says proper coding is particularly important when a beneficiary has more than one chronic condition and underlying disease problems that must be consistently documented from year to year in order to obtain appropriate reimbursement from Medicare. “If a member with diabetes has retinopathy, for example, we have to make sure that our documentation shows these diagnoses each year,” he says.
Even two years ago, says Dodson, the C-SNP in particular was an unknown concept. But XLHealth leaders saw it as a way to get a leg up on the competition and began offering it to a small number of beneficiaries in eight counties in Maryland. In 2007, Care Improvement Plus expanded into three additional counties in Maryland, as well as statewide preferred provider offerings in three designated CMS regions:
1. Missouri and Arkansas
3. South Carolina and Georgia
Also, in 2007, CMS began reimbursing all SNPs at 100% risk-adjusted payments. The total number of plan options grew from 43 in 2006 to 241 in 2008. As for Care Improvement Plus, the total enrollment numbers increased from just under 500 in 2006 to approximately 75,000 at the end of 2007. “We anticipate that our growth rate will stabilize this year. However, we have continued to make strides in new enrollments thus far in 2008 within our existing service areas,” says Dodson.
An advantage for SNPs over other Medicare DM offerings is the flexibility. The legislation that created SNPs allows plans to target beneficiaries with specific conditions and build benefit packages tailored to those conditions.
In a traditional Medicare Advantage model, benefits are created for a broader population and not designed around a specific chronic condition, says Harry Leider, MD, XLHealth’s chief medical officer.
Care Improvement Plus offers seven benefit packages. Coordinated care and DM modalities are included in each option.
The SNP model provides an opportunity for better integration of DM efforts, says Dodson, compared to working with fee-for-service beneficiaries, such as those in Medicare Health Support or another pilot program.
According to a recent CMS announcement, the Medicare Health Support pilot program has not met certain criteria and will end in 2008. “In a fee-for-service environment, the provider is trying to infiltrate from the periphery; whereas in a SNP model, the beneficiaries are plan members and as a result providers can more easily gather important medical and health-related data to stratify and manage members effectively,” Dodson says.
Role of independent brokers
Dodson says the company has learned that the success of SNPs is also tied to the role of the independent broker and how well the brokers know the Care Improvement Plus product. “Broker education is critical industrywide,” he says. “We are one of the few plans that didn’t delegate this responsibility outside the organization.”
Brokers should know every aspect of the C-SNP benefit, including the different drugs covered in the Medicare Part D prescription drug benefit offered through Care Improvement Plus.
Care Improvement Plus offers a prescription drug benefit that centers on chronic DM, Dodson says.
Prescription drugs that members need to best manage their chronic disease, but that may not be available in generic, are incorporated into the Care Improvement Plus formulary.
For example, top diabetes drugs, such as Metformin, Avandia, and Actos, are often used in combination. They are expensive and could well put the Medicare beneficiary over the $2,510 limit that triggers the “donut hole” in coverage.
“Adding these drugs to the formulary and offering low to no copay levels for certain disease state medications has been a distinct advantage for our members,” says Dodson.
The drug benefit and other C-SNP offerings have clearly provided much richer services than enrollees had under previous Medicare coverage, says Dodson.
“The challenge for knowing how well disease management strategies are faring in this market is that we have little to benchmark against,” he says. “We believe that we will continue to improve quality and lower costs in 2008.”
Editor’s note: Next month, we will feature the first Medicare Advantage SNP specifically for people with chronic disease and dementia.
CMS/NCQA propose SNP quality measures
CMS has asked the National Committee for Quality Assurance (NCQA) to develop a set of structure and process measures for special needs plans (SNP).
“This is a first step in evaluating the quality of care that it provided to Medicare beneficiaries who are receiving care from these new Medicare Advantage plans,” says Kerry Weems, CMS acting administrator. CMS data shows that there were 470 SNPs covering more than one million beneficiaries in 2007; a total of 760 SNPs have been approved for 2008.
The quality measures will examine how SNPs set up case management programs for members with complex needs and how they act to improve clinical care and the patient experience, Weems says.
In addition to quality and process measures, CMS will require that SNPs report 13 HEDIS measures to assess performance. These must be reported by June 30 and include:
Colorectal cancer screening (except for SNPs under PPO contracts, because these measures rely on medical record review)
Glaucoma screening in older adults
Spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD)
Pharmacotherapy for COPD exacerbation (first-year measure is optional for all Medicare Advantage reporting)
Controlling high blood pressure (except PPO contracts)
Persistence of beta blocker treatment after a heart attack
Osteoporosis management in older women
Antidepressant medication management
Follow-up after hospitalization for mental illness
Annual monitoring for patients on persistent medications
Potentially harmful drug-disease interactions
Use of high-risk medication in the elderly
NCQA President Margaret O’Kane says that NCQA’s geriatric measurement advisory panel will help develop the structure and process measures in the following areas of care: integration of benefits and services, case management, care transitions, member experience, and clinical quality improvement.
The accreditation organization released the proposed standards for public comment in December 2007 and planned to announce proposed final requirements to CMS by March 15.
Final requirements and data collection tools will be available to SNPs in mid-April, with submission due by June 30.
Every SNP benefit package with an effective date of January 1, 2007, will be required to submit HEDIS results, and every benefit package, regardless of start date, must report quality and process measures.
O’Kane also says that NCQA will conduct training sessions over the Web to inform SNPs about pertinent information regarding the process for submitting data through NCQA’s data collection tools and the requirement for SNP evaluation.
Dates and times for training are available on the NCQA Web site at www.ncqa.org.